The number of residents in cognitive decline in aged care is only going to go up, however, some cost-effective steps can provide a safer, healthier environment for all involved.

In many locations across Australia, there are insufficient places available for people with dementia in memory support units within residential aged-care facilities. This means retirement village operators are increasingly grappling with how to provide safe, supportive and enjoyable environments for residents with diminishing cognition.

Firstly, let’s explore the depth of the issue. In 2015, there were about 190,000 seniors living in retirement villages; this number is projected to increase to close to 400,000 by 2050. The average age of those residents is 81 and the incidence of people with dementia aged 80–85 is 11 per cent for men and 14 per cent for women – and it increases with age (see table on opposite page). The depth of the challenge for RV operators is obvious.

Over the next 30 years, the number of people with dementia will treble (2016: 353,800 people with dementia in Australia). A useful guide for estimating the number of residents in your village with dementia is the RV Dementia Prevalence Calculator found in The Dementia Guide for the Australian Retirement Village Industry, Alzheimer’s Australia2015. Be aware that there are probably many more residents without a diagnosis of dementia who are in various stages of cognitive decline. It is generally accepted that it is, on average, three years from first onset of dementia to diagnosis.

WHAT keeps operators UP at night

Many operators’ minds are occupied with questions such as:

How do we find the right balance between providing a suitable environment for people with dementia and retaining appeal for other residents and their families?

What physical modifications are required in our village to meet our duty of care to residents to keep them safe, and what are the costs vs returns?

What care and services do I need to consider to support these residents, especially when they live alone?

How do I ensure an inclusive and supportive organisational culture within my team?

What are the legal risks? How do I appropriately discharge my duty of care?

This article aims to provide a framework to commence planning.

Where to Start

The most vital step for operators of existing villages is to develop an environmental risk identification and management strategy. This facilitates a systematic, process for prioritising and planning modifications to the village. It also enables operators to budget accordingly. Operators who undertake this process testify that it empowers them, giving them a feeling of being in control of the situation and, most importantly, facilitates meeting their duty of care.

The first component of this process is an incident audit. This means undertaking an analysis of incidents over the past 12 months involving people diagnosed with dementia and those with known cognitive challenges. Use a site plan of the village to mark up where those incidents occurred and consider how the physical environment may have directly or indirectly contributed to those incidents.

Next, develop a ‘gap analysis’ of the site and relevant buildings (both communal and residents’ houses) in conjunction with a trusted specialist who has experience designing for people with dementia. This involves walking around the site identifying risk points, while being practical regarding the level of risk exposure for residents and your tolerance as an operator for that risk. It is also useful to unobtrusively observe residents with cognition challenges, as this can highlight concerns that otherwise may be overlooked.

Completing this two-step process will enable the development of a strategic risk-management plan with prioritised, achievable actions, time lines and budgets. Without this, the outcome may be a shotgun approach that misses the target.

Prepare to modify

With a plan in place, simple changes to the village can make a world of difference to a person with dementia and do not necessarily need to be cost prohibitive.

The Dementia Training Study Centre at the University of Wollongong provides guiding principles to help reduce the frustration, anxiety, depression and sometimes anger and aggression that can arise for residents in environments that are confusing and unsupportive.

Here are some examples of how these principles may be applied. Firstly, ensuites may need modifications. They are frequently unsuitable for people with diminishing cognition and are an area of risk. Some suggested changes for operators to discuss with residents and their families include: installing low-wattage LED lights over toilets to provide an immediate sight cue, particularly if the toilet is visible from the bed; replacing white toilet seats with a contrast colour; installing vanities with contrast colours between the bench top and the basin.

Secondly, kitchens in independent living units also can be modified with some reasonably simple adjustments. Operators can replace solid-form kitchen cupboards with glazed inserts, so residents can easily see what is inside the cupboard. Open shelving can be edged with a contrast colour to differentiate it from the supporting frame. It’s also a good idea to ensure there is colour or tonal contrast between the floor, cupboards, bench top and back splash.

Externally, garden paths that lead residents away from certain areas, as well as camouflaged and integrating gates and fencing, have a high degree of acceptance from all residents – they don’t feel institutional – and can easily be done. Enabling wayfinding for residents so they feel more confident and secure as they navigate the village doesn’t require large capital expenditure. Consider garden layouts and theming: review locations of large dense shrubs that may obscure vision, and prune as necessary. Provide garden seating locations at 20-metre intervals. Introduce colour or fragrance theming to gardens; provide auditory cues, such as garden chimes or water features. These simple measures will help residents navigate and will enhance emotional and physical safety.

At some older villages each independent living unit’s exterior looks similar, which is confusing for residents trying to find their way home. Painting the front face of each unit a strong and easily recognisable colour can assist, as can personalising features such as letter boxes, front doors and pot plants. Again, simple measures with great benefits.

Safety on site

Securing the perimeter of the village, most particularly the front entrance, can be challenging. This is perhaps the biggest concern for operators of existing villages where residents have begun to wander. Newer village operators are increasingly designing their villages with a single point of secure entry and exit and secure courtyards for those who may wander.

Technology provides many solutions with varying price ranges for both existing and new villages. Geo-fencing, closed-circuit TV, wrist monitors and movement sensors for unit interiors are all available. Residents who are engaged within the village – for example, with raised gardens, potting sheds or men’s sheds – and feel safe and comforted are less likely to wander.

There is no one answer to the vexed and challenging reality that confronts many operators. However, a systematic analysis of the issues specific to your village is a good place to start.